Sent to us by the author.
Supplements and Health – by Rolf Hefti
The Background To This Issue Of Mammogram Screening
“When I tell the truth, it is not for the sake of convincing those who do not know it, but for the sake of defending those that do.” (William Blake, 1757-1827, Engraver, Artist, and Visionary)
In February of 2014 a follow-up analysis of a mammogram study (a large randomized controlled trial), the Canadian National Breast Cancer Study (CNBSS), got published at the BMJ (formerly the “British Medical Journal”).
The study authors concluded that the organized implementation of mammographic breast cancer screening has not significantly reduced mortality from breast cancer over a standard form of breast care -that is, a physical breast exam (=doctor breast exam). Instead, the scientists found notable harm from mammograms via overdiagnosis. (By the way, the CNBSS is among the many mammogram studies I had cited in my (e)book “The Mammogram Myth“.)
This 2014 update of the Canadian mammogram study (CNBSS) received quite a bit of media attention and resulted in the submission of many commentaries (rapid responses) to the BMJ journal. These electronic letters, if approved by the editor, get published at the official website of the BMJ.
On May 1, 2014, Alan Cassels, the author of “Seeking Sickness: Medical Screening and the Misguided Hunt for Disease” (2012), made this statement about the outpouring of CNBSS responses:
“With over 60 online ‘comments’ published following that article, it’s one of the most insightful sets of ‘back and forth’ discussions on breast cancer screening you will ever read.” [I]
You can freely access all of the published letters/comments to the Canadian mammogram trial at: the BMJ website.
I had submitted a number of commentaries. The first got published on 14-Feb-2014. Starting with my second mammogram letter, on 18-March-2014, I got engaged in a bit of an ongoing debate with a mammogram supporter (Jacob Levman, PhD). In Levman’s commentary on 22-April-2014 he accused me of spreading “opinions” about mammograms. I prepared another response for submission, addressing Levman’s allegation, and sent it in to the BMJ on 24-April-2014.
Yet, to my surprise, the BMJ did not publish it unlike what they had done with all of my previous electronic submittals. I contacted the letters editor of the BMJ to find out why my latest submission did not get approved and released but my inquiry was ignored.
Because I felt my BMJ-censored commentary illuminates worthwhile background information on the politics permeating the mammogram debate (that in 2014, it seems, still isn’t commonly known by much of the general public), I decided to publish the piece on my own website.
My suppressed BMJ mammogram entry follows here exactly as I had submitted it to the journal of the British Medical Association (for a thorough understanding of its content I would strongly advise to first read all of the prior responses between Levman and myself that can be freely accessed at the aforecited link to the BMJ website).
Note: don’t miss my epilogue (afterword) following my unpublished BMJ letter below:
Title: Re: Accusations of Bias Versus Actual Bias Regarding Mammography
In his most recent letter Levman makes a concerted effort and point to dismiss my commentaries as my “opinions” . Supposedly, he states reliable evidence or the actual facts while I state my own personal “opinions”. Although, I had provided consistently more references than Levman to help prevent giving the impression that my statements are my “opinions”. Slander of the individual is a common, albeit unsophisticated, manner of chasing away disagreement or a threat, or distracting the public’s attention away from critical issues and data.
Levman  tries to substantiate his effort to denigrate my input on the discussion with further unjustly accusing me of largely unsubstantiated things like “being biased”, having resorted “to weak and misleading tactics”, putting out “opinions supported by arguments based on no relevant research training”, “citing papers that don’t support the statements presented” or “producing quotations not included in the studies cited” when in fact Levman had exactly done much of that in some of his previous (and current) letters which I had elucidated in prior responses (e.g., think of his severely misleading and false portrayal of Gøtzsche’s stance on the value of mammography. It is clearly his own “opinion”, not a fact. I have to presume it is an “opinion” of Levman “supported by arguments based on” much “relevant research training”. Needless to say, the “cited papers” of Gøtzsche’s “don’t support the statements presented” by Levman). How come there is no mention of this in his finger-pointing at me, are you not supposed to notice? Does this omission qualify as a “weak and misleading tactic”? Perhaps the reader should ask what the real purpose of Levman’s accusations are.
You can judge for yourself whom the aforecited allegations most strongly apply to by carefully reading through our past exchanges and by closely investigating the supplied references for yourself.
Levman’s commentaries have now shifted from thematic focus to ad hominem attacks, confirmed by his last response . This move is in alignment with a traditional, broader schemata among a number of fierce mammogram supporters:
Akin to Levman’s allegations of my commentaries (e.g., my “opinions” “may very well lead to preventable breast cancer deaths” ), the pro-mammogram community routinely denounces, or tries to disable, dissenting voices with fear-mongering language aimed at coercing women into continuing to get mammograms. For instance, the recent highly critical report by the Swiss Medical Board on mammography , that advocated to stop introducing new systematic screening programs based on their conclusion the test’s severe harms don’t justify its minor benefits, was declared “unethical” by mammogram organizations . What, for instance, is “unethical” -the acknowledgment of relevant data on harm or their disregard? Where is Levman’s purported concern for women on the grave extent of harm from in situ overdiagnosis/overtreatment, leading most probably to unnecessary thus “preventable breast cancer deaths” in numerous women, that he had wrongly and misleadingly dismissed [see my prior response, part 1, from 11-April-2014]?
Yet, such “weak and misleading tactics” are abound in the literature and works of the mammogram industry. For instance, mammography-critical people with arguably much “relevant research training”, such as Peter Gøtzsche, MD, Per-Henrik Zahl, MD, PhD, Gilbert Welch, MD, or Cornelia Baines, MD (from the BMJ study at hand ), are dismissed and stigmatized as “a group of pseudo-skeptics” . Besides accusing mammogram-dissenting voices as stating “opinions”, the work of mammogram critics had also been reduced to “fiction”, “guesswork”, “assumptions”, and “nonsense and nonscience” by representatives of the mammogram industry [5-7].
Evidently, the overall crude theme (or political game, or “weak and misleading tactic”) is that the public ought to see that the pro-mammography perspective allegedly epitomizes “reliable evidence/actual facts” instead of “opinions”/”nonscience”, while the anti-mammogram view is based on “opinions”/”nonscience” instead of “reliable evidence/actual facts”, thus mammography-critical “opinions” and “guesswork” are very dangerous to women.
The resort to slander and depreciation of mammography-disagreeing voices and works by the mammogram community has increased roughly in proportion to the accumulating amount of anti-mammogram data. Does that signify the correctness of the pro-mammography position or its incorrectness?
What perhaps might be of further public interest and pertinence in regard to mammography is that Levman had disclosed that he is currently only associated with the “Centre of Excellence in Personalized Healthcare, Institute of Biomedical Engineering” at Oxford. In some of his recent research papers from 2011/2012 and December 2013 it denotes that he’s also affiliated with “Imaging Research, Sunnybrook Research Institute, University of Toronto” [8,9], a group that among other things sponsors research in mammogram technology .
And, both of these studies were funded by the Canadian Breast Cancer Foundation, a pink ribbon charity that claims to provide “you with evidence-based information about mammography screening”  and that supports the use of mammography and makes the claim that “mammography has helped to reduce deaths from breast cancer by more than 35 per cent” in Canada since the late 1980s , which is in deep contrast to what the here principally discussed Canadian National Breast Screening Study by Miller and colleagues  found, but that is in solid accordance with the standard claims of benefit made by the mammogram industry or their mouthpieces.
The Imaging Research, Sunnybrook Research Institute, University of Toronto announced in the summer of 2010 on their official website that Levman had received a two-year “fellowship worth $95,000” from the Canadian Breast Cancer Foundation . However, in several response letters by Levman to a BMJ study in November 5th, 2010 , November 11th, 2010 , November 12th, 2010 , and August 19th, 2011 , where he praises the value of mammography (“Mammography is a well established screening method”  -echoing the claims of his pink ribbon group sponsor), defends its use over other traditional screening modalities , while criticizing the value of the alternative screening modality of thermography , he publicly declared to having no competing interests in each of his commentaries. Personal vested interests of study authors tied to the mammogram industry, including having been funded by cancer charities, lead to an imbalanced emphasis (also known as bias) of “the major benefits of mammography screening over its major harms” and more frequent dismissal of harms  (a pattern reflected with remarkable consistency across Levman’s aforecited BMJ letters and his current BMJ rapid responses on the Miller group study ).
At this point I feel a re-iteration of a statement of mine from my last letter is most appropriate:
Historically, secrecy, complexity, and vested interests mean one thing: control of a specific ideology by a certain group of people, whether political or medical.
Based on this study  it is clear that a person with so-called “relevant research training” is fully capable of producing “nonscience” or biased “opinions”. It supports the notion that having “relevant research training” isn’t a prerequisite or necessity to arrive at the actual facts of the matter, arguably, it may even be an obstacle in that regard. It also illustrates that other things are very meaningfully relevant in arriving at the actual facts, such as the recognition of the urgent need to always look for conflict-of-interests among study authors (or people and organizations with “relevant research training”), among people and organizations that forcefully criticize people who express mammogram-disagreeing views, among people who admonish women not to listen to people with an anti-mammogram position, and behind officially and popularly accepted medical practices, dogmas, and views.
Levman remarked  that it is “clearly important to accurately assess the mortality benefits of mammographic breast cancer screening, whatever they may be”, yet a person with vested interests linked to the mammogram industry, evidently, cannot “accurately assess” the mortality benefits of mammography because he/she is biased (=not in a position to objectively evaluate benefits and harms from the test) due to competing interests.
Exaggerating benefits, downplaying and ignoring harms of mammography … doesn’t the medical industry assure the public of their adherence to the axiom, “first, do no harm” that unmistakably suggests the preferential emphasis ought to be on harm infliction instead of on benefit derivation? Especially since organized mammography screening is geared towards healthy women, as almost all women undergoing screening do not have breast cancer at the time of examination . Where are the cries of outrage from mammogram proponents, the calls that the stark violation of their leading moral pledge of concern for the public is “unethical”? Apparently, personal vested interests pertaining to industry are fully capable of corrupting the credo of “first, do no harm” unapologetically.
The imbalanced emphasis on benefits over harms of mammography indicates that there is probably a lack or loss of proper concern for women among many vested-interest-afflicted authors of pro-mammogram studies in terms of harm women might receive. And, do the all-too-common hidden, denied, or undeclared conflicts-of-interests among study authors with affiliations to the mammogram industry reassure you that these people have an exceedingly sincere interest or concern for the well-being of women at large and that they are reliably unbiased?
Also, do findings, results, statements, or conclusions based on significant bias due to vested interests, resemble reliable evidence/actual facts or rather “nonscience” and personal “opinions” of the person(s) tied to self-serving interests? The fact that such biased “studies” get routinely published in acclaimed medical journals and officially pass as, and are recognized as, reliable scientific evidence is instructive of how conventional medical research works. “Nonscience” passes as science because it is sanctioned by some body (or bodies) of authority.
The greater the conflicts-of-interests and the greater the frequency thereof in the pro-mammogram literature, the greater and more widespread this particular bias about the actual merit of mammography. No wonder women were consistently found to have a very wrong perception of the true benefit of mammography [3,17] (you guessed it, they believed it is very high) after getting inundated and indoctrinated by predominantly pro-mammogram information based on studies that frequently are sponsored by the massive mammogram industry (including the pink ribbon organizations), and because major mammographic harms are typically not mentioned to women when invited to organized screening programs because the organizers of the programs have also a conflict-of-interest , all of which going on for decades.
Therefore, should women trust this widely disseminated “scientific” information on mammography, much of it coming from people/groups with conflicts-of-interests and thus is reliably biased, or should they trust the mammogram information of people with “relevant research training”, such as Per-Henrik Zahl, MD, PhD, Peter Gøtzsche, MD, or Karsten Jørgensen, MD, who actually do not downplay or reject the severe harms of mammography, or overemphasize its benefits respectively, because they are not bogged down and compromised by vested interests allied to the mammogram industry, leading them to generate a mammogram-friendly perspective?
Finally, I will not divert more time to responding to Levman’s disparaging ad hominem attacks because I honestly feel they are undeserving of such and because the field of mammography is littered by politics. Within this general framework, and contrary to Levman’s authoritative advice for women to “ignore” my “opinions”, I’m not advising women (or anyone else) on what or whom you should or should not ignore but instead I’m going to basically reiterate emphatically what I had stated previously:
My sincerest hope is that the public recognizes the urgent necessity to pro-actively examine the evidence on mammography from both sides of the debate, but particularly from the dissenting side because the general public had been fed consistently, repeatedly, and almost exclusively pro-mammography information over the last few decades, having created a tainted unilateral platform of knowledge that effectively impedes or prevents the formation of a truly “informed choice” about the procedure, manifested in data showing women have a very wrong perception of the true benefit of mammography . Actually doing so will equip you and help you to constructively differentiate more reliably between “opinions”/”fiction” and evidence, enabling you to discern quite logically what you can “ignore” or not without having so-called authorities on mammography to tell you, thence allowing you to make a increasingly reasonable “informed choice” on mammography.
- Levman J, “Re: Accusations of Bias Versus Actual Bias Regarding Mammography”, British Medical Journal, 348:g366, 22-April-2014.
- Swiss Medical Board, “Systematisches Mammographie-Screening”, Pp. 1-83, 15-Dec-2013 [www.medical-board.ch; accessed 22-April-2014]
- Biller-Andorno N, Jüni P, “Abolishing Mammography Screening Programs? A View from the Swiss Medical Board”, N Engl J Med. 2014 Apr 16. [Epub ahead of print]
- Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA, “Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial”, BMJ. 2014 Feb 11;348:g366. doi: 10.1136/bmj.g366.
- Tabár L, http://www.mammographyed.com/Resources/15266/
FileRepository/Rebuttal%20Videos/LECTURE_Part_Two.pdf [accessed 22-April-2014]
- Kopans DB, “The most recent breast cancer screening controversy about whether mammographic screening benefits women at any age: nonsense and nonscience”, AJR Am J Roentgenol. 2003 Jan;180(1):21-6.
- Dean PB, Tabár L, “Mammography’s alleged harms: Separating fact from fiction”, www.auntminnie.com, Dec. 13, 2012
- Levman J, “Re: effectiveness of computer-aided detection in community mammography practice”, J Natl Cancer Inst. 2012 Jan 4;104(1):77-8; author reply 78-9. doi: 10.1093/jnci/djr491. Epub 2011 Dec 20.
- Levman J, “Longitudinal disease detection rates for the evaluation of disease detection technologies with application in high-risk breast cancer screening”, J Clin Diagn Res. 2013 Dec;7(12):2932-5. doi: 10.7860/JCDR/2013/5693.3794. Epub 2013 Oct 22.
Mammography/Pages/default.aspx [accessed 22-April-2014]
- http://sunnybrook.ca/uploads/sri_nexus_2010summer.pdf [accessed 22-April-2014]
- Levman J, “Detection rates and mortality for evaluating breast cancer screening” British Medical Journal, Reply to 340:c3106, 5-Nov-2010 [http://www.bmj.com/rapid-response/2011/11/03/detection-rates-and-mortality-evaluating-breast-cancer-screening -accessed 22-April-2014]
- Levman J, “On comparing the harms and benefits of breast cancer screening”, British Medical Journal, Reply to 340:c3106, 11-Nov-2010 [http://www.bmj.com/rapid-response/2011/11/03/comparing-harms-and-benefits-breast-cancer-screening -accessed 22-April-2014]
- Levman J, “Clarification on detection rates and mortality for evaluating breast cancer screening”, British Medical Journal, Reply to 340:c3106, 12-Nov-2010 [http://www.bmj.com/rapid-response/2011/11/03/clarification-detection-rates-and-mortality-evaluating-breast-cancer-scree -accessed 22-April-2014]
- Levman J, “On Digital Infrared Thermal Imaging for Breast Cancer Detection”, British Medical Journal, Reply to 340:c3106, 19-Aug-2011 [http://www.bmj.com/rapid-response/2011/11/03/digital-infrared-thermal-imaging-breast-cancer-detection -accessed 22-April-2014]
- Jørgensen KJ, Klahn A, Gøtzsche PC, “Are benefits and harms in mammography screening given equal attention in scientific articles? A cross-sectional study”, BMC Med. 2007 May 30;5:12.
- Domenighetti G, D’Avanzo B, Egger M, Berrino F, Perneger T, Mosconi P, Zwahlen M, “Women’s perception of the benefits of mammography screening: population-based survey in four countries”, Int J Epidemiol. 2003 Oct;32(5):816-21.
- Jørgensen KJ, Gøtzsche PC, “Content of invitations for publicly funded screening mammography”, BMJ. 2006 Mar 4;332(7540):538-41.
Competing interests: Author of the (e)book “The Mammogram Myth” (2013)